Cork University Dental School and Hospital - Doctoral Theses
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Item Clinical need and economic factors: influencing orthodontic care in a sample of patients in Ireland(University College Cork, 2023) McDermott, Patricia Ann; Woods, Noel; Higher Education AuthorityAIM: The primary aim of the thesis is to investigate factors impacting on the child, adolescent, or parent in their decision to seek orthodontic care. The study has three objectives: 1) To investigate clinical and non-clinical factors influencing pre-treatment perceived need for orthodontic care by both parent and child/adolescent 2) To determine the amount a parent is willing to pay (WTP) pre and post treatment in order to obtain the benefit of straight teeth for their child, and 3) To investigate factors that influence patient compliance (in terms of hygiene) during fixed appliance treatment. The investigation is important in the current economic environment as orthodontic services tend to be an extremely expensive intervention and can be publicly funded. The research is influenced by studies highlighting that perceptions of need for care are multi-factorial and often influenced by non-clinical elements. Recent studies have highlighted the necessity for essential behavioural propensity assessment. RATIONALE: As orthodontic services are an expensive healthcare intervention, it is important to continue to examine the factors that may affect demand and outcomes in publicly funded and privately funded healthcare systems. There are very few studies on WTP in mainstream orthodontics. METHOD: It is a prospective longitudinal study using convenience sampling. The sample was stratified by age and gender, and consists of 177 subjects from the Republic of Ireland (RoI) and 177 from Northern Ireland (NI). The treatment modality was fixed appliance orthodontic treatment. The patients, aged 12 to 18 years (mean = 13.5), were studied in three different healthcare funding systems, from recruitment in 2004 until the completion of follow-up questionnaires in 2008. Instruments used to collect data included a patient administered interview at both pre- and post-treatment, two parent self-administered instruments, and a compliance instrument administered by the orthodontist. The pre- and post-treatment models were scored using Peer Assessment Rating (PAR), and the Index of Orthodontic Need (IOTN). The Dental Health Component (DHC) and the Aesthetic Component (AC) were scored by orthodontists. The orthodontists administering the treatment judged compliance and questionnaires were completed three months from the start of treatment and at the time the braces were removed. The data was analysed descriptively and empirically. The empirical analysis was undertaken using bivariate and multivariate regression analysis. RESULTS: The results indicate a misalignment between professionally assessed IOTNAC, and the child’s perceived need. Perceived need for orthodontic treatments was more pronounced in children treated in privately funded healthcare systems and was influenced by peer groups in both public and private funding systems. Parental factors influencing perceived need were the appearance of their children’s teeth and gender differences. Parents from both NI and RoI had high perception of need levels with no significant difference between parents who are publicly funded or those who pay fees privately. Willingness to pay at the pre-treatment was associated with higher parental income and WTP did not change pre- and post-treatment. Parents from the RoI were willing to pay more than their NI counterparts, and this was true, whether or not, they were paying full societal or subsidized fees. Parental WTP pre-treatment and at completion is closely related to the societal market values for the jurisdiction and was related to ability to pay in both funding systems. There was no difference in the level oral hygiene compliance by those treated in either funding system. Compliance during treatment was better in females and children/adolescents from higher income households. More highly compliant children/adolescents had better treatment outcomes and lower PAR scores. CONCLUSIONS: The misalignment between perceived need and normative need may be due to lack of education in terms of what is a socially acceptable level of dento-facial appearance. The expectations of publicly funded patients/parents and their misalignment between perceived need and the value they place on treatment may not always be grounded, in practical realities but rather in external influences. Means testing would help public systems identify those who cannot afford treatment, but have a definite need for treatment. Practitioners and policy makers should consider whether the criteria for qualification for orthodontic treatment in healthcare systems should include an assessment of oral hygiene levels and cooperation. This thesis contributes by highlighting the importance of patient and parental perception and societal expectations on the demand for orthodontic care. In terms of behavioural propensity, the study provides an insight into the qualification for treatment based on potential behavior during treatment. The study has developed a practical tool for use by practitioners to gain an insight into the possible compliance of a child, depending on what is motivating them to seek treatment.Item Periodontal disease prevelance and oral hygiene in adults with cystic fibrosis(University College Cork, 2023) Coffey, Niamh; Hayes, Martina; Roberts, Anthony; Burke, Francis M.; Cystic Fibrosis Ireland; Health Research BoardObjectives This research had four objectives: 1. To review the available literature regarding studies on oral hygiene levels and prevalence of periodontal disease in people with Cystic Fibrosis (PWCF) -Chapter 3 2. To assess and analyse the oral hygiene and dental attendance patterns of adults with Cystic Fibrosis (CF) – Chapter 4 3. To explore the attitudes of PWCF towards dental attendance and any perceived barriers to treatment – Chapter 5 4. To determine and analyse the prevalence of gingivitis and periodontitis in a cohort of adults with Cystic Fibrosis – Chapter 6 Methods There were three methods of investigation employed to achieve these objectives: 1. A systematic review of available literature regarding oral hygiene and periodontal disease in PWCF 2. A cross-sectional mixed-methods study in the form of a structured anonymous questionnaire 3. A clinical study examining the oral hygiene levels, gingival and periodontal condition in adults with Cystic Fibrosis Results Objective 1. The search resulted in 614 publications from databases. One more publication was identified by searching bibliographies. Thirteen studies were included in the qualitative analysis. Five studies found lower levels of gingivitis in the CF group compared to the control group/general population. Four studies found no difference in gingivitis levels between CF and non-CF groups. Three studies found higher levels of calculus in PWCF. Objective 2. A total of 71 adults with Cystic Fibrosis responded to the survey. While the majority of respondents (66.2%) saw a dentist in the preceding year, 15.5% had not attended a dentist for over two years. Smoking and alcohol consumption levels were low. 63.4% brushed twice or more daily, with 70.4% using a Fluoride containing toothpaste. 62% did not use any interdental cleaning aid. 5.6% changed their toothbrush at least once a month, but for 22.5% it was over six months. 38% snacked three or more times daily and 29.5% consumed fizzy drinks at least once daily. Objective 3. The qualitative portion of the survey found that 54.9% of respondents were unhappy with their teeth. 63.4% felt that CF had an impact on oral health. 33.8% were anxious about attending their dentist. 54.9% felt that dentists should be part of the multidisciplinary team. Respondents believed that CF has impacted on their oral health due to the medications and dietary requirements involved, as well as tiredness and other side effects of CF. Some reasons for being anxious about attending the dentist involved cross infection concerns, issues with the dentist, with tolerating treatment, and with the teeth themselves. They wanted dentists to be aware of the practicalities of dental treatment for people with CF, especially their discomfort with lying back. They also want the dentist to be aware of the impact their medication, treatment and diet has on their oral health. Objective 4. A total of 92 PWCF took part in the clinical study. The median age was 31 years, with an interquartile range (IQR) of 25-35.75 (control group: median age 27 years, IQR 25-35.75). The CF group was comprised of 54 men and 38 women (control group: 43 men and 49 women). This study found that PWCF brushed less frequently than the control group, interdental cleaning was lower, and more PWCF were unsure if their toothpaste contained fluoride, or if they qualified for dental check-ups under the PRSI dental scheme. They had similar rates of dental attendance; however, they were more likely to be symptomatic attenders, i.e., attend for pain/a problem. Assessment of the oral hygiene status showed that the plaque and calculus levels were statistically higher in the CF group. Despite this, there were lower levels of gingivitis, mild periodontitis and severe periodontitis in the CF group. There were no links between the use of Pancreatic Enzyme Replacement Therapy (PERT) or Cystic Fibrosis Transmembrane conductance Regulator (CFTR) modulators or diabetic status on either the periodontal or oral hygiene status of the CF group. Gingivitis, mild periodontitis and plaque levels are all higher in PWCF who do not take antibiotics, however the difference was not statistically significant. Conclusions Objective 1. The majority of previous studies showed lower levels of gingivitis and plaque among PWCF compared to controls. However, a number of studies showed that PWCF had higher levels of dental calculus. Three studies found no difference in oral hygiene levels. Objective 2. The alcohol and tobacco consumption in the qualitative study was low. However, a large proportion of PWCF frequently consumed sugar-rich foods, and they did not change their toothbrush, brush their teeth or attend the dentist as regularly as is advised. More targeted advice is necessary to improve the oral hygiene habits of adults with CF. Objective 3. Over a third of adults with CF are anxious regarding attending the dentist. Reasons for this include fear, embarrassment, cross infection concerns and problems with treatment, especially being in the supine position. Dentist and dental care professionals should be aware of the impact that CF can have upon dental treatment and oral health care. Objective 4. Adults with CF had higher levels of plaque and calculus than a control group. Despite this, they had lower levels of clinical gingivitis and periodontitis. Further study is required to examine the causes of this phenomenon. More targeted oral hygiene advice should be given to PWCF in order to reduce their future risk of development of periodontal conditions, as well as inhalation of oral pathogens.Item Impact of downward adjustment of water fluoride concentration on dental caries and fluorosis(University College Cork, 2022-12-20) James, Patrice; Whelton, Helen; Harding, Mairead; O’Mullane, Denis; Perry, Ivan J.; Cronin, Michael; Health Research BoardIntroduction: Community water fluoridation (CWF) was initiated in Ireland in 1964 at a concentration of 0.8 to 1 ppm fluoride. In 2007, in the context of ongoing reductions in dental caries with increasing prevalence and severity of dental fluorosis, water fluoride concentration in Ireland was adjusted to 0.6 to 0.8 ppm with the aim of reducing the prevalence and severity of dental fluorosis while maintaining reductions in dental caries. Aim: To determine the difference in dental caries and fluorosis levels following downward adjustment of CWF concentration. Methods: Ethical approval was obtained from the Clinical Research Ethics Committee (CREC) of the Cork Teaching Hospitals. A before and after study compared dental caries and fluorosis in random samples of 8-year-olds in Dublin (n=707) and Cork-Kerry (n=1,148) in 2016-17 with 8-year-olds in Dublin (n=679) and Cork-Kerry (n=565) in 2002. Dentinal caries experience in primary teeth (d3vcmft(cde)) and fluorosis in permanent teeth (Dean’s Index, whole mouth score) were clinically measured by trained and calibrated dentists. Standardised oral photographs were taken (8 seconds drying) for children in Cork-Kerry in 2016-17 and 2002. Fluorosis (Thylstrup-Fejerskov (TF) Index) in permanent maxillary central incisors was scored from the photographs in duplicate by two trained and calibrated dentists, blind to fluoridation status and year, with disagreements resolved by consensus. Person-level TF score was the highest score in the central incisors. Children were categorised as having lifetime or no exposure to CWF (Full-CWF/No-CWF). Effect of examination year on dental caries prevalence (d3vcmft(cde) > 0) and severity (mean d3vcmft(cde) among children with caries experience) and fluorosis prevalence (Dean’s ‘very mild’ or greater, TF 1 or greater and TF 2 or greater) were evaluated using multivariable regression controlling for the effects of other explanatory variables. Additional multivariable regression analyses evaluated the effect of CWF on dental caries prevalence and severity and fluorosis prevalence in 2002 and 2016-17, before and after the downward adjustment, respectively. Results: After controlling for the effects of other explanatory variables, children in Cork-Kerry in 2016-17, with lifetime exposure to CWF at 0.6 to 0.8 ppm fluoride, had lower caries prevalence (56% vs. 65%) and severity (mean d3vcmft(cde) 3.7 vs. 4.2) in primary teeth than their counterparts with No-CWF. Among children with Full-CWF, there was no statistically significant difference in caries prevalence or severity between 2002 and 2016-17. In 2016-17, caries prevalence was 55% in Dublin (Full-CWF) and 56% in Cork-Kerry (Full-CWF) and mean d3vcmft(cde) among children with caries was 3.4 and 3.7, respectively. Among children with No-CWF, caries severity was less in 2016-17 (mean 4.2) than 2002 (mean 4.9) (P = 0.039). The difference in caries severity between children with Full-CWF and No-CWF was less in 2016-17 than 2002 (Interaction P = 0.013), suggesting a reduced benefit for CWF in 2016-17. In 2016-17, fluorosis prevalence (Dean’s Index) was 18% in Dublin (Full-CWF) and 12% in Cork-Kerry (Full-CWF). Fluorosis was predominantly ‘very mild’ with no statistically significant difference between 2002 and 2016-17. Fluorosis prevalence in permanent maxillary central incisors was predominantly TF 1 and TF 2 and was lower in Cork-Kerry in 2016-17 than in 2002 at both case definitions. Among children with Full-CWF, prevalence of TF 1 or greater was 40% in 2016-17 and 75% in 2002 (OR 0.24, 95% CI [0.17, 0.34], P < 0.001) and prevalence of TF 2 or greater was 15% in 2016-17 and 27% in 2002 (OR 0.50, 95% CI [0.33, 0.75], P = 0.001). At both time points, fluorosis prevalence measured using Dean’s Index and the TF Index was higher among children with Full-CWF than their counterparts with No-CWF (2002 and 2016-17, P < 0.001). Conclusion: There was no reduction in fluorosis prevalence measured clinically using Dean’s Index in 2016-17 compared with 2002. However, fluorosis prevalence in the aesthetically important maxillary central incisors measured blind to year and fluoridation status from oral photographs was reduced following downward adjustment of water fluoride concentration. Based on the cross-sectional comparison of children with Full-CWF and No-CWF in 2016-17, the lower concentration of 0.6 to 0.8 ppm fluoride is an effective caries-preventive measure. However, the before and after study indicated that downward adjustment of water fluoride concentration may have reduced the caries-preventive effect of CWF in primary teeth. Further research is needed to evaluate the impact of the downward adjustment on dental caries in permanent teeth of children and adults with CWF.Item Determining competence in prosthodontics in undergraduate dental school programmes: an international study(University College Cork, 2022-12-09) Al Khalaf, Khaleel; Lynch, Christopher D.; Da Mata, CristianeBackground and aims: In an era of increased attention on patient safety, as well as increased student mobility between many countries, it is of interest to investigate contemporary international trends in the teaching and assessment of prosthodontics. The aims of this PhD project were to investigate the teaching and assessment methods of the prosthodontics domains and to determine if it is possible to agree on competency standards in prosthodontics. Structure and methods: This thesis includes an introductory chapter (Chapter 1), a narrative review of relevant educational and prosthodontic literature (Chapter 2), four original quantitative (questionnaire-base) studies to assess the contemporary teaching and assessment methods of prosthodontics on international basis (Chapters 3-6), and a mixed-method Delphi approach among prosthodontic/restorative dentistry experts to obtain a consensus on the most suitable undergraduate teaching and assessment methods (Chapter 7). Chapter 8 includes a qualitative study using one-to-one interview to explore the perspectives and opinions of senior dental academics that did not reach consensus using the Delphi method. Chapter 9 contains a systematic review synthesising the response rates in dental literature of questionnaire-base studies. Finally, a brief conclusion of the thesis was presented (Chapter 10). Results: Narrative review: there was significant divergence among prosthodontic curricula in dental schools in terms of teaching methods, assessment criteria and how student competence is determined. Quantitative studies: Our findings from the quantitative studies reinforced the findings of the narrative review; there was a significant international divergence of undergraduate teaching and assessment trends among dental schools, including the preclinical and clinical course, of the prosthodontics divisions (complete denture, removable partial denture, fixed prosthodontics and dental implants). Divergence was evident in dental schools even within the same country. Mixed-method Delphi and qualitative studies: A total of 23 senior academic experts from 11 countries participated in the Delphi study. There was a high level (92.6%, 175 statements out of 189) of consensus agreement over three iterative rounds, whereas 14 statements (7.4%) did not achieve a consensus. A total of 12 senior dental academics from seven countries participated in semi-structured interviews, it was agreed that academic professors, consultants, or specialists were the most suitable staff members to supervise students during preclinical hands-on sessions in removable and fixed prosthodontics. In addition, participants mentioned the availability of suitable patients for treatment, dental schools’ curriculum and the level of students’ skills as factors influencing the starting point of clinical sessions in fixed prosthodontics. We also found differences among the participating schools in regard to course contents and extent of teaching on dental implants. The experts suggested tailoring the curriculum according to what is expected from the graduating dentists and allowing students to observe dental implant cases before treating simple cases. Systematic review of response rate: Overall, 133 studies with 149 response rates were included. The median response rate across the included studies was 77%, a significant negative correlation was observed between the response rate and the actual number of distributed questionnaires (sample size) (r = -0.4127; P<0.001). there was an association between the response rate and the area of distribution (e.g., national or international, P= 0.0012). Yet, it was unclear whether if there are correlations between the response rate and other variables (e.g., piloting, number of questions and the journal impact factor). Conclusions: This thesis highlighted the current divergence in teaching and assessment methods of undergraduate prosthodontics. However, this divergence can be minimized, and the international harmonization of the dental curricula is highly possible by reassessing and tailoring the dental curricula. We presented a list of senior academics’ consensus statements on the teaching and assessment methods of prosthodontics. In addition, multiple recommendations and challenge resolutions were suggested and introduced. Thus, our findings can be considered as guidelines and references to develop recommendations for stakeholders involved in undergraduate curricula among dental schools worldwide and in consistence with the local dental council recommendations, which will ensure dentists with the same level of competence at graduation.Item Comparison of statural height growth velocity with chronological age and dental development at different cervical vertebral maturation stages in a contemporary Irish population(University College Cork, 2021-07) Coffey, Diarmuid John; Millett, DeclanAim: The aim of this study was to investigate if a correlation exists between CVM stage and statural height growth velocity, chronological age and dental development in a contemporary Irish population. Materials and Methods: Following ethical approval, a total of 269 subjects were recruited from the orthodontic treatment waiting list at Cork University Dental School and Hospital (CUDSH). All participants had a digital lateral cephalogram and DPT as part of their initial orthodontic records. Standardised standing height was also measured at this initial appointment and at subsequent 6 to 8 week intervals for approximately one year to calculate a mean annualised growth velocity (MAGV). A single calibrated observer assessed CVM stage from lateral cephalograms using the method described by Baccetti et al., (2005) and dental development stage of the mandibular second permanent molar from each DPT using Demirjian’s Index. Chronological age was determined from the subject’s chart. Statistical analysis of MAGV, chronological age and stage of dental development were performed using ANOVA, with CVM and gender as factors. Pairwise comparisons were made between CVM stages. Results: The final sample comprised of 218 subjects (121 females, 97 males), with a mean age of 14.02 (SD 1.97) years and age range of 8.82-18.77 years. Intra-observer (ĸ = 0.97) and inter-observer (ĸ = 0.94) reliability of CVM stage assessment were ‘almost perfect’. Intra-observer reliability for dental development stage was also ‘almost perfect’ (ĸ = 0.97). There was a statistically significant difference in MAGV between CVM stages (p<0.0001) and between genders (p<0.0001). The peak in statural height growth velocity occurred at CVM stage 3 in both males (mean age 13.39 (SD 0.75) years) and females (mean age 11.95 (SD 0.82) years). Chronological age exhibited significant differences between CVM stages (p<0.0001) and between genders (p<0.0001). There was also a statistically significant difference in the distribution of dental development stage between CVM stages (p<0.0001) and between genders (p=0.0292). Conclusions: • MAGV differed significantly between successive CVM stages in both males and females, with the peak in statural height growth velocity found at CVM stage 3. • Chronological age differed significantly between CVM stages, and these differences were dependent on gender. • The distribution of dental development stages differed significantly between CVM stages and between genders.